TOW #6: Concussions

Unfortunately, summer is known as "trauma season" at Harborview when we see a peak of youth injuries, especially head trauma. In addition to summer recreational activities, youth around our area are starting camps and early practices for the fall sports season. So, this is an opportune time to review concussions, a very hot topic in pediatrics (and society-at-large, for that matter). We as pediatricians are increasingly called upon to address these injuries in clinic and clear youth for return to activities. Below are teaching materials for this week. Also check out R3 Emilie Weigel's great RCP review on concussion which she presented this month.

Links for this week's materials: Concussion Case and Discussion and AAP Statement on Concussion

Key take-home points for concussions:

  1. Epidemiology: Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports (possibly due to higher reporting). Loss of consciousness occurs in about 10% of concussions-but may signal a more severe injury.
  2. Concussion definition: complex pathophysiological process affecting the brain with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  3. Work-up should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Also review any assessments done at the time of injury (e.g. SCAT3, etc). You can also complete these in the office, such as the SCAT3 version used at HMC. Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation.
  4. Imaging: CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See HMC algorithm for determining need for CT after head injury. This HMC algorithm is based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. Treatment: Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games)-this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here's a handout to use that reviews return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking.

Check out resources from our sports medicine experts here.

Have a great week!

Mollie

TOW #5: Water Safety

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children's has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents: http://www.seattlechildrens.org/dp

Check out this week's teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water.
  2. Definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid" and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm's reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Pediatricians have a role in drowning prevention. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Remind families about water safety and where to get information, including handouts here: http://www.safekids.org/watersafety

Have a wonderful week! Hope you get to enjoy some of your own safe and fun time in the water this summer.

TOW #4: Health Literacy

In pediatrics, we care for children of very diverse backgrounds, providing some of the joy of our work. One challenge for parents is interpreting our guidance and instructions. This is especially difficult if parents have lower health literacy, which encompasses reading and numeric interpretation. Sarah Zaman, a recent graduate, did her R3 resident case presentation (RCP) on her research to assess parents’ knowledge of their child’s diagnosis, and she showed that many parents do not even understand the basics of the diagnosis.

The beginning of the academic year is a great time to review how we can best assess health literacy, and learn to provide information to families to ensure they understand us. (Stay tuned for another topic to review limited English proficiency)

Here are the materials for this week: Health Literacy Case and Discussion 2015   Article: Health Literacy – Gap Between Physicians and Patients AFP 2005

Take-home points on assessing and augmenting health literacy:

  1. Health literacy is defined by the AMA as “the ability to perform basic reading and numerical tasks required to function in the health care environment.”
  2. No matter what literacy a person has, a "universal precautions" approach is recommended: meaning we should explain things as clearly as we can to everyone (e.g., my spouse, who has a non-medical doctorate and a better vocabulary than me, reminds me often how important it is to discuss health issues with him without medical terminology.)
  3. Low health literacy is common. More than 1/3 of adults are considered to have basic or below basic health literacy, meaning they may struggle with understanding growth charts, immunization schedules or dosing medication. Be aware that many people read below the highest grade they completed, and most adults read at an 8th-9th grade level, while health care material is often written at a 10th grade level.
  4. Assess health literacy using validated tools or, more practically, understanding risk factors: for pediatric caregivers these include not completing 12th grade, not living with the child’s other parent, and not reading for pleasure. These are all associated with 6th grade or below reading level.
  5. Use effective strategies to improve understanding. One is the Teach-Back Method of asking parents to repeat back the plan. Another very effective approach is to use pictures. A review of articles that used pictures in medical teaching showed that patients recalled 1.5-2 times more information with pictures.

TOW #3: Agenda Setting in outpatient care

This week we continue a tour of topics relevant to learning how to be effective in the overall approaches to outpatient general pediatrics. One of the challenges of providing well child and acute care is operating within time constraints, especially when you get a "door knob complaint".  Focused agenda setting is one way to stave off important issues being brought up at the last minute when you think you are done with the appointment and are headed out the door. I can attest that many a time I wish I had more carefully probed for the parent's or teenager's agenda! Hopefully this review will help us remember to do it effectively.

Here are the materials for this week:

Take home-points for agenda-setting:

  1. A patient or their parent may often not bring up their primary concern immediately, especially if it is something embarrassing. Asking "what else" and then "what else" can help us elicit all concerns and set priorities.
  2. The likelihood of psychosocial complaints being brought up without asking about them is even lower.
  3. Some studies have found that about half of patient's complaints and symptoms were not elicited in an interview.
  4. Doing agenda-setting well has been found to only add seconds to the visit.
  5. Parents will be okay with addressing some items later if the importance is validated, an attempt is made to deal with the most pressing ones, and it is done up-front in the visit.

Have a great week! -Mollie

TOW #2: Infant and Toddler Development

Welcome to our warm start to July! Next week is a chance to review cognitive and motor development for children, always a fun topic. Please review the Infant and Toddler development case discussion 2015 and 2 Pediatrics in Review articles on development – Motor Development – Peds in Review 2010 and Cognitive Development – Peds in Review 2010. The motor development one is the most comprehensive so if you can only do that one, I’d recommend it.

Take-home points for infant and toddler development:

  1. Epidemiology: ~12-15% of children and adolescents in the US have a developmental disability and ~20% meet diagnostic criteria for a mental health disorder.
  2. Assessing development: includes surveillance which occurs at every WCC visit (asking about parents’ concerns, keeping a developmental hx, observing child, identifying risk factors, documenting findings) and formal screening with a validated tool like ASQ (AAP recommends at 9 mo, 18 mo, or 30 mo). Specific autism screening is recommended at 18 and 24 mos.
  3. Types of development: developmental milestones are assessed in major areas of language and communication, fine and gross motor, cognitive and social-emotional domains. If delayed, we need to figure out which areas are involved. Global delay is more likely associated with medical conditions.
  4. Work-up: if concerned based on surveillance or screening, pay close attention to growth, especially head circumference, dysmorphology, neuro exam, and skin exam.
  5. Treatment: Any delays identified warrant follow-up and referral to Birth-to-Three for further evaluation (the benefit of the 24 mo visit provides one additional time to assess development before the window closes for birth-to-three options).

Happy 4th! As I’m on call at HMC for the holiday this year, I am hoping everyone has an especially safe and happy one!

Mollie